Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract

BACKGROUND: Endoscopic ultrasound is widely used following endoscopy for evaluation of suspected submucosal lesions and may guide further management of patients. PATIENTS AND METHOD: A total of 181 consecutive patients with suspected submucosal lesion in the upper gastrointestinal tract were diagnosed by endoscopic ultrasound between 1990-97. We evaluated: 1) the potential of endoscopic ultrasound criteria to predict histological type of submucosal lesions in 69 patients with available histology, 2) the ability of endoscopic ultrasound alone or with clinical presentation, to predict malignancy in 86 patients with available histology or follow-up of >12 months. RESULTS: Sensitivity and specificity for diagnosing 44 gastrointestinal stromal tumours were 95 and 72%, respectively, while 25 miscellaneous lesions were diagnosed correctly in only 56% by endoscopic ultrasound. Diagnosis of malignancy, using any two of three endoscopic ultrasound criteria (heterogeneous echotexture, size >3 cm, irregular margins) showed a sensitivity of 80% and specificity of 77%, giving accurate endoscopic ultrasound diagnosis in 16/20 malignant and 51/66 benign submucosal lesion. Heterogeneous echotexture, size >3 cm, and irregular margins showed a relative risk of 7.2, 5.4 and 4.6, respectively, for presence of malignancy. The presence of symptoms, potentially suggesting malignancy (dysphagia, gastrointestinal bleeding, pain and weight loss), had a relative risk of 4.2, however this did not increase the accuracy of diagnosing malignancy based on endoscopic ultrasound criteria alone. CONCLUSION: The accuracy of endoultrasound is high in diagnosing gastrointestinal stromal tumours, which show a significant potential of malignancy. Endoscopic ultrasound morphology appears to be helpful in selection of patients for surgical or conservative treatment. The accuracy of endoscopic ultrasound in differential diagnosis of non-gastrointestinal stromal tumour lesions is limited.     

The Outcome Assessment of Double-Balloon Enteroscopy for Diagnosing and Managing Patients with Obscure Gastrointestinal Bleeding

Diagnosing and treating patients with obscure gastrointestinal bleeding is clinically challenging. Most lesions responsible for the origin of obscure gastrointestinal bleeding are located in the small bowel. Double-balloon enteroscopy is a novel method for exploring the small intestine and has significant therapeutic potential. This study evaluated the value of double-balloon enteroscopy in diagnosing and managing obscure gastrointestinal bleeding. From October 2003 to January 2006, a total of 20 patients (6 men, 14 women; mean age, 55.2 years old) with obscure gastrointestinal bleeding (18 obscure overt bleeding, 2 obscure occult bleeding) were investigated by double-balloon enteroscopy. A total of 29 procedures (15 via oral approach and 14 via rectal approach) were performed. The diagnostic yield, endoscopic therapeutic procedures, complications, and outcome were then assessed. Small bowel lesions potentially responsible for the bleeding were identified in 15 (75%) of 20 patients, including 9 angiodysplasias, 2 gastrointestinal stromal tumors (GISTs), 2 ulcers, 1 jejunal granulation polyp, and 1 Peutz-Jeghers polyposis. Endoscopic treatments including heater probe coagulation, polypectomy, and endoscopic mucosal resection were performed in 11 patients. Two patients with GISTs received surgical intervention. Two patients with angiodysplasias that endoscopic treatment failed underwent laparoscopic resections following tattooing. There were no complications and the procedures were tolerated well. Among the 15 patients who had a lesion identified with subsequent treatment, rebleeding occurred in 3 (20%) patients with angiodysplasias. Of the five patients in whom no definite lesion was detected, rebleeding developed in four (80%). For patients with an identified lesion that was further treated, the rebleeding rate was lower than for those with “persistent” obscure gastrointestinal bleeding (P=0.031). We conclude that double-balloon enteroscopy offers a safe and effective method for diagnosing and managing patients with obscure gastrointestinal bleeding.     

Is upper gastrointestinal radiography necessary in the initial management of uncomplicated dyspepsia?

Study objective: To compare two strategies for the evaluation and management of patients who have had acute dyspepsia for four days or more: empiric high-dose antacid therapy combined with patient reassurance (empiric care) versus therapy based on prompt upper gastrointestinal radiography (traditional care). Design: Prospective, randomized trial. The patients in the empiric care group were reassured that upper gastrointestinal radiography was not necessary and were subsequently treated with high-dose empiric antacid therapy (15–30 ml of high-potency antacid one and three hours after meals and at bedtime). The traditional care group received upper gastrointestinal radiography as part of the initial evaluation. Subsequent treatment was determined by individual physicians based on test results. Settings: Fee-for-service, hospital-based primary care practice and Veteran’s Administration medical center outpatient clinic. Patients: All patients were less than 70 years of age and without gastrointestinal bleeding, anemia, significant weight loss, or other specified symptoms of severe acid peptic disease. Fifty patients were randomized to traditional care, and 51 to empiric care. Pre-randomization clinical features were identical with the exception of sex distribution and baseline disability. Measurements and main results: After six months of follow-up, there were no significant differences in symptom scores, disability, satisfaction, and quality of life measures (as measured by the Sickness Impact Profile scores) between the two groups. Findings were unchanged when adjusted for sex, study site, alcohol consumption, and cigarette smoking. Of the radiographs obtained in the traditional care group, 13 (27%) showed duodenal ulcer disease, gastritis, or duodenitis. There were no serious complications of ulcer disease or therapy noted in either group. The average costs per patient associated with traditional care at one study site were greater, $286 versus $116 (p<0.0001). Conclusions: Select patients with dyspepsia receiving a combination of reassurance and empiric antacid therapy do as well as patients whose initial management strategy includes upper gastrointestinal radiography, at a substantially lower cost. Supported by grants from the Massachusetts Fund for Cooperative Innovation, Massachusetts Hospital Association, and Blue Cross of Massachusetts (60%); the Massachusetts General Hospital (30%); and William H. Rorer, Inc., Fort Washington, Pennsylvania (10%).     

Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia

Gastrointestinal bleeding is believed to cause iron-deficiency anemia (IDA). The information concerning ideal evaluation of the gastrointestinal tract and exact findings in patients with IDA is scant. The aim of this study was to prospectively evaluate patients with IDA for gastrointestinal lesions potentially causing IDA at a US Army Teaching Medical Center with Gastroenterology Fellowship. Seventy patients with IDA had esophagogastroduodenoscopy (EGD) and colonoscopy, and if this evaluation was unremarkable, then small bowel biopsy was obtained at EGD to evaluate for celiac disease. Enteroclysis was done if endoscopic evaluation was negative. At endoscopy, at least one lesion potentially accounted for the IDA in 50 (71%) patients. At colonoscopy, 21 (30%) patients had 22 lesions (four colon cancer, seven adenoma>1 cm, six vascular malformation, four severely bleeding hemorrhoids, one ileal Crohn's); at EGD, 39 (56%) patients had 43 lesions (11 gastric erosion, 10 esophagitis, four vascular malformation, four celiac disease, three gastric cancer, three gastric ulcer, three duodenal ulcer, two gastric polyp>1 cm, one duodenal lymphoma, one esophageal cancer, and one duodenal Crohn's). Twelve (17%) patients had both upper and lower gastrointestinal tract lesions. Twenty-four of 32 (75%) patients with positive fecal occult blood test had potentially bleeding lesions compared to 24 of 38 (63%) patients with negative fecal occult blood test (P>0.05). Six of nine patients with malignancy had positive fecal occult blood test. Twenty patients with normal endoscopy and small bowel biopsy had normal enteroclysis. It is concluded that the combination of colonoscopy and EGD identifies potential bleeding sources in most patients with IDA. In the absence of a potential bleeding lesion, small bowel biopsy at EGD is essential to diagnose celiac disease.The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.     

Scintigraphic Determination of Gastrointestinal Transit Times: A Comparison with Breath Hydrogen and Radiologic Methods

A scintigraphic method for determination of gastrointestinal transit times was compared with the breath hydrogen test and a multiple-bolus, single-radiograph technique. A close temporal association was found between the caecal appearance of radioactivity and the onset of breath hydrogen excretion in eight healthy subjects. Neither mean small-intestinal nor mean orocaecal transit times of the radiolabeled marker were correlated with the magnitude of hydrogen peak, hydrogen peak time, or the area under hydrogen curve. No correlation was noted between whole-gut transit time of the radiolabeled marker and mean whole-gut transit time calculated from a 6-day administration of the radiopaque marker in 16 healthy subjects. The stool weight was inversely correlated with the mean colonic (r = -0.46, p = 0.009) and the mean whole-gut (r = -0.45, p = 0.011) transit times of the radiolabeled marker. In conclusion, inadequate delineation of the caecal region seems to be an unimportant drawback of the scintigraphic measurements, whereas day-to-day variation in gastrointestinal transit rates may influence the reliability of the assessments. Probably, quantitative transit data cannot be obtained from the breath hydrogen concentration profiles.     

Intestinal ischemia as the first manifestation of vasculitis

OBJECTIVE: To summarize current knowledge regarding the diagnosis and management of gastrointestinal vasculitis. METHODS: Three cases of gastrointestinal vasculitis with acute abdominal ischemia as their first manifestation are presented. Underlying diseases were microscopic polyangiitis, systemic lupus erythematosus (SLE), and polyarteritis nodosa (PAN). Relevant English-language articles collected from the PubMed database were reviewed. RESULTS: Among the angiitides, PAN, SLE, and Henoch-Sch?nlein are those most commonly accompanied by gastrointestinal complications. Intestinal vasculitis usually occurs when there is evidence of generalized disease activity. Abdominal computerized tomography is a valuable tool for diagnosing intestinal ischemia and suspected vasculitis. CONCLUSIONS: In young patients presenting with intestinal ischemia, it is essential to assess the possibility of an underlying systemic disease. With prompt initiation of immunosuppressive treatment, surgery may be avoided. Prognosis is improved when there is minimal delay in surgical intervention.     

Diagnostic Yield and Impact of Capsule Endoscopy on Management of Patients with Gastrointestinal Bleeding of Obscure Origin

This study assessed diagnostic yield and impact of capsule endoscopy on patient management. Seventy-five patients with obscure gastrointestinal bleeding were included. Clinical and followup information was collected by review of patient records and with personal contact with the referring physicians. All previous clinical information and interventions after capsule endoscopy and clinical outcome were noted. The indication was obscure-overt gastrointestinal bleeding in 36 patients (48%) and obscure-occult gastrointestinal bleeding in 39 patients (52%). Overall diagnostic yield was 66.7% considering relevant lesions. Followup was available in 31 patients. Capsule endoscopy changed clinical management in 61.4%. Multivariate analysis showed that patients with another potential source of bleeding and patients whose onset was hematochezia were not good candidates for capsule endoscopy. Capsule endoscopy has a high diagnostic yield and a positive influence on clinical management in a high proportion of patients with obscure gastrointestinal bleeding.     

Unexplained gastrointestinal symptoms: Think mitochondrial disease

Defects in mitochondrial function are increasingly recognised as central to the pathogenesis of many diseases, both inherited and acquired. Many of these mitochondrial defects arise from abnormalities in mitochondrial DNA and can result in multisystem disease, with gastrointestinal involvement common. Moreover, mitochondrial disease may present with a range of non-specific symptoms, and thus can be easily misdiagnosed, or even considered to be non-organic.We describe the clinical, histopathological and genetic findings of six patients from three families with gastrointestinal manifestations of mitochondrial disease. In two of the patients, anorexia nervosa was considered as an initial diagnosis. These cases illustrate the challenges of both diagnosing and managing mitochondrial disease and highlight two important but poorly understood aspects, the clinical and the genetic.The pathophysiology of gastrointestinal involvement in mitochondrial disease is discussed and emerging treatments are described. Finally, we provide a checklist of investigations for the gastroenterologist when mitochondrial disease is suspected.     

The validity of suspected blood indicator software in capsule endoscopy: a systematic review and meta-analysis

Introduction: Software tools have been developed as capsule endoscopy (CE) reading aids. The suspected blood indicator (SBI) tags possible areas of haemorrhage in the gastrointestinal (GI) tract. This meta-analysis aims to investigate the diagnostic accuracy of SBI in CE.

Areas covered: A systematic literature search was conducted for studies on the use of SBI in CE. Sensitivity, specificity and diagnostic odds ratio (DOR) of SBI in diagnosing GI bleeding was evaluated. 2040 patients from 16 studies underwent 2049 CE examinations. The overall sensitivity of SBI for bleeding or potentially bleeding lesions was 0.553, specificity 0.578, DOR 12.354. The sensitivity of SBI for active bleeding was 0.988, specificity 0.646, DOR 229.89.

Expert commentary: Currently, SBI has limited validity in CE reading. However, in active GI bleeding, it has good sensitivity, supporting its use in the acute setting.     

Endoscopic submucosal dissection for premalignant lesions and noninvasive early gastrointestinal cancers

AIM: To investigate the indication, feasibility, safety, and clinical utility of endoscopic submucosal dissection (ESD) in the management of various gastrointestinal pathologies. METHODS: The medical records of 60 consecutive patients (34 female, 26 male) who underwent ESD at the gastroenterology department of Kocaeli University from 2006-2010 were examined. Patients selected for ESDhad premalignant lesions or non-invasive early cancers of the gastrointestinal tract and had endoscopic and histological diagn...     

胃肠道结核的内镜与病理

目的总结胃肠道结核的内镜诊断经验，以引起对这个特殊疾病的重视，减少漏诊和误诊。方法内镜检查发现胃肠道黏膜隆起、结节、红斑、溃疡等病变，行黏膜活检病理。结果7例患者中，胃结核2例，其中溃疡型1例，增殖型1例；肠结核5例，其中增殖型4例，混合型1例。病变部位：胃窦部2例，回肠末端1例，回盲瓣1例，回肠末端和回盲瓣1例，回肠末端及结肠多处病变1例，升结肠1例。内镜诊断：1例结合有浸润型肺结核诊断为肠结核，2例诊断为结肠恶性肿瘤，4例诊断为胃肠黏膜隆起或溃疡性病变性质待定。7例患者活检组织病理均为干酪样坏死肉芽肿，符合结核。结论胃肠道结核病内镜下表现多种多样，与结肠癌、克罗恩病等炎性肠病及胃良恶性溃疡难以鉴别，需依赖黏膜活检病理诊断。     

Vascular Malformations of the Small Intestine

Opinion statement Vascular malformations of the small bowel are uncommon, yet remain a cause of gastrointestinal bleeding in up to 5% of patients with gastrointestinal hemorrhage. The diagnosis of these lesions is suspected in patients with a gastrointestinal source of blood loss with a negative upper endoscopy and colonoscopy. Enteroscopy remains the mainstay in diagnosing these lesions. Therapeutic options include endoscopic coagulation, pharmacologic agents (hormones, octreotide, iron replacement), and occasionally surgery. Pharmacologic and endoscopic treatments are discussed.     

Miniprobe sonography in the evaluation of 169 patients with gastrointestinal disease

OBJECTIVE : It is still difficult to precisely differentiate elevated lesions of the gastrointestinal mucosa or estimate the depth of malignant lesions by using conventional endoscopy and biopsy. The aim of the present study was to assess the clinical value of miniprobe sonography (MPS). METHODS : A total of 169 patients (including 83 patients who underwent endoscopic treatment or surgery) with gastrointestinal disease were examined by using MPS in conjunction with endoscopic examination. The diagnosis according to MPS was compared with macroscopic findings, endoscopic biopsy and surgical results. RESULTS : In the case of elevated lesions of the gastrointestinal mucosa with negative biopsies, compared with surgical findings, the diagnostic accuracy of MPS was 98.3% (115/117). In the case of malignant lesions, MPS findings with regard to the lesion depth were 100% in agreement with those from surgical biopsy (31/31). CONCLUSION : The MPS technique is significantly superior to conventional endoscopy with pathological biopsy in the differentiation of elevated lesions of the gastrointestinal mucosa and thus has important clinical value. But in the case of malignant lesions, only the depth of infiltration into the gastrointestinal wall can be correctly assessed by MPS, so its value is limited in the identification of lymph nodes and distal metastases.     

消化内镜联动成像技术临床应用建议

联动成像技术(linked color imaging,LCI)是一种新型图像增强内镜技术,目前已在临床上逐步应用。多项研究证实,LCI可通过增加内镜下病变黏膜和正常黏膜的对比度来提高对消化道黏膜病变的诊断准确率。尽管LCI临床应用价值已经得到了国内外临床医生的广泛认可,但是在应用过程中也暴露出技术使用不够规范、术语翻译混乱等问题,不利于后续临床和研究工作的开展。为此,本建议依据当前LCI诊断消化道病变的最近研究和循证医学证据,并参照国内外最新研究成果,由国内消化内镜知名专家集体讨论并编制而成。     

Narrow band imaging with magnification for the diagnosis of lesions in the upper gastrointestinal tract

Endoscopy plays an important role in the diagnosis and management of gastrointestinal(GI)tract disorders.Chromoendoscopy has proven to be superior to white light endoscopy for early detection of various GI lesions.This has however been fraught with problems.The use of color stains,time taken to achieve an effect and the learning curve associated with the technique has been some of the pitfalls.Narrow band imaging(NBI)particularly in combination with magnifying endoscopy may allow the endoscopist to accomplish a fairly accurate diagnosis with good histological correlation similar to results achieved with chromoendoscopy.Such enhanced detection of pre-malignant and early neoplastic lesions in the gastrointestinal tract should allow better targeting of biopsies and could ultimately prove to be cost effective.Various studies have been done demonstrating the utility of this novel technology.This article will review the impact of NBI in the diagnosis of upper gastrointestinal tract disorders.     

Effect of cimetidine on marathon-associated gastrointestinal symptoms and bleeding

Occult gastrointestinal bleeding occurs in 8–30% of marathon runners. We hypothesized that cimetidine would decrease bleeding by reducing acid-mediated injury and conducted a blinded, placebo-controlled prospective trial to determine the impact of cimetidine on gastrointestinal symptoms and bleeding during a marathon. Thirty participants in the 1989 Marine Corps or New York City marathons completed pre- and postrace: (1) a questionnaire evaluating demographic, medication usage, training history, and gastrointestinal symptoms; (2) three consecutive stool Hemoccult (HO) cards; and (3) a stool Hemoquant (HQ). Fourteen runners (CR) took 800 mg of cimetidine by mouth 2 hr before the start and 16 runners (PR) took placebo. Three subjects were HO+ prerace and were not analyzed. Three subjects failed to take drug as directed and were analyzed as PR. Five of 14 PR and two of 13 CR were HO+ postrace (P>0.05). Prerace HQ values (PR: 1.49 ±0.6 and CR: 0.60±0.1 mg hemoglobin/g stool) were not significantly different from postrace HQ values (PR:0.73±0.2 and CR:0.86±0.2 mg Hgb/g stool). Despite postrace HO+ conversion, no individual postrace HQ became abnormal. The frequency of gastrointestinal symptoms was similar for CR and PR, as well as HO- and HO+ individuals. Cimetidine did not significantly affect occult gastrointestinal bleeding as measured by HO or HQ results. This suggests that marathon-associated gastrointestinal symptoms and bleeding may be due to lesions other than acid-mediated disease or hemorrhagic gastritis.This work was presented in part at the 1990 Digestive Disease Week Annual Scientific Meeting, American Gastroenterological Association, San Antonio, Texas, May 16, 1990, and published in abstract form in Gastroenterology 98:A91, 1990.Work supported by: US Naval Medical Research and Development Command, Grant NN0007589 WR 00016.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, the Department of Defense, or the Uniformed Services University of the Health Sciences.     

糖尿病伴发的上消化道病变电子胃镜检查诊断疾病特点分析

目的探讨糖尿病伴发的上消化道病变电子胃镜检查诊断疾病特点。方法选取2017年1月—2019年4月收治的30例糖尿病合并上消化道病变患者与30例单纯上消化道病变患者作为研究对象,均实施电子胃镜检查。结果两组在食管黏膜、胃底红斑、胃底胃窦红斑对比中差异无统计学意义(P>0.05);而两组在贲门口、空腹血糖、餐后2 h血糖对比中差异有统计学意义(P<0.05)。两组在食管糜烂、十二指肠糜烂、复合型溃疡对比中差异无统计学意义(P>0.05);两组在胃糜烂、2个部位以上糜烂、胃溃疡、十二指肠溃疡对比中差异有统计学意义(P<0.05)。结论电子胃镜用于糖尿病合并上消化道病变中具有较高的临床价值,可为疾病区分提供客观依据。     

隐源性消化道出血的病因及诊断分析

目的总结分析隐源性消化道出血的病因,探讨不同检查方法的诊断价值。方法对1992年至2004年的39例经手术治疗消化道大出血临床资料进行回顾性分析。结果39例患者均有病理诊断,所有病变以良性为主58.97%(23/39),病变部位以小肠居多89.74%(35/39)。与病理结果比,选择性动脉造影诊断符合率为56%(14/25),核素扫描定位诊断符合率为38.53%(13/34),小肠插管分段气钡造影诊断符合率为22.58%(7/31),术中内窥镜诊断符合率85.71%(6/7)。结论疑难消化道大出血病变多数在小肠,以良性病变为主,术前选择性动脉造影具有较高的定性和定位诊断价值。     

How much helpful is the capsule endoscopy for the diagnosis of small bowel lesions？

AIM: To assess the practically usefulness and diagnostic yield of this new method in a group of patients with suspected small bowel lesions. METHODS: Capsule endoscopic (CE) examination by using M2A capsule endoscope TM (Given Imaging, Yoqneam, Israel) was performed in thirty nine patients (26 males, 13 females) with suspected small intestinal lesions. The composing of the patients was as follows: obscure gastrointestinal bleeding in twenty three patients, known Crohn's disease in 6 patients, in whom CE was used to evaluate the severity and extension of the diseases, chronic diarrhea in 8 patients, abdominal pain in one patient and malignancy in one patient with unknown origin. RESULTS: In two patients CE failed. Different abnormalities were revealed in 26 patients overall. Detection rate of abnormalities was highest among patients with obscure gastrointestinal bleeding and the source of bleeding was demonstrated in 17 of 23 patients with obscure bleeding (73.9%). Entero-Behcet was diagnosed in two patients by CE as a source of obscure gastrointestinal bleeding. In 6 patients with known Crohn's disease, CE revealed better evaluation of the disease extension. In 3 of 8 (37.5%) patients with chronic diarrhea; CE revealed some mucosal abnormalities as the cause of chronic diarrhea. In a patient with unexplained abdominal pain and in a cancer patient with unknown origin, CE examination was normal. CONCLUSION: In our relatively small series, we found that capsule endoscopy is a useful diagnostic tool particularly in diagnosis of obscure gastrointestinal bleeding, chronic diarrhea and in estimating the extension of Crohn's disease.     

Ultraslim endoscopy with flexible spectral imaging color enhancement for upper gastrointestinal neoplasms

AIM:To conduct a preliminary study on the effect of flexible spectral imaging color enhancement (FICE) used in combination with ultraslim endoscopy by focusing on the enhanced contrast between tumor and non-tumor lesions. METHODS: We examined 50 lesions of 40 patients with epithelial tumors of the upper gastrointestinal tract before endoscopic submucosal dissection using ultraslim endoscopy with conventional natural color imag ing and with FICE imaging. We retrospectively invest igated the effect of the use of FICE on endoscopic diagn osis in comparison with normal light. RESULTS: Visibility of the epithelial tumors of the upper gastrointestinal tract with FICE was superior to normal light in 54% of the observations and comparable to normal light in 46% of the observations. There was no lesion for which visibility with FICE was inferior to that with normal light. FICE visualized 69.6% of hyperemic lesions and 58.8% of discolored lesions better than conventional endoscopy with natural color imaging. FICE sign if icantly improved the visibility of lesions with hyp ere mia or discoloration compared with normocolored lesions. CONCLUSION: This study suggests that the use of FICE would improve the ability of ultraslim endoscopy to detect epithelial tumors of the upper gastrointestinal tract.